Information Collection

Statement of Authority to Act for Employee

IC 33846 under ICR 202012-3220-003 · OMB 3220-0034.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0034 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SI-10 (05-17) Statement of Authority to Act for Employee	Form
Form SI-10 (05-17) Statement of Authority to Act for Employee Statement of Authority to Act for Employee	Form
SI-10 (05-17) Statement of Authority to Act for Employee Form SI-10 (05-17).pdf	Form
SI-10 (05-17) Statement of Authority to Act for Employee Form SI-10 (05-17).pdf	Form
Form SI-1a (03-12).pdf SI-1a, Application for Sickness Benefits	IC Document
Form SI-1a (03-12).pdf SI-1a, Application for Sickness Benefits	IC Document
Form SI-1b (06-09).pdf SI-1b, Statement of Sickness	IC Document
Form SI-1b (06-09).pdf SI-1b, Statement of Sickness	IC Document
Booklet UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees Booklet	IC Document
Booklet UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees Booklet	IC Document

IC Title:

Statement of Authority to Act for Employee

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 335.2 20 CFR 348

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SI-10 (05-17)				No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Insurance Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30	-2	32
Annual IC Time Burden (Hours)	3	0	3
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SI-1a, Application for Sickness Benefits		10/13/2017
SI-1b, Statement of Sickness		10/13/2017
UB-11, Sickness Benefits for Railroad Employees Booklet		10/13/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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